Erythroblastosis Evaluation
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Erythroblastosis Evaluation | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
ERYTH
Test Workstation :
BBANK
Specimen Type:
Blood
Tube Type:
Red top (no anticoagulant) tube, red micro tube( newborn patient only)
Collection Volume:
6 mL red top from biological mother of patient and 0.5 mL from Baby
Minimum Volume:
4.0 red top from biological mother of patient, 0.5 ml patient
Preferred Volume:
6 mL red top from biological mother of patient and 0.5 ml from patient
Cause for Rejection:
Improperly identified specimen, gross hemolysis
Storage:
Room Temperature Transport
Availability:
Daily, 24 hours
Methodology:
Tube Testing
Special Instructions:
Label the tube with a patient identification label (2 identifiers). Collector employee ID#, date, and time must be added to the label at collection.
All Blood Bank specimens must be accompanied by a completely filled out Blood Bank Requisition to include two signatures at the time of specimen collection.
Mislabeled Blood Bank Specimens will not be processed, regardless of the situation. Specimens for Blood Bank testing with any type of mismatched or missing information must be redrawn.
For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly)
Lab/Phone:
330-543-8723
TAT:
1 hour (STAT); 4 hours (Routine)
CPT Code:
86900
Synonyms:
Erythro Workup; Hemolytic Disease of the Newborn Workup
